Nurses can relate to scenes of disruptive behavior and intimidation, such as verbal outbursts and threats of reporting a person, to the more passive actions, such as refusing to return phone calls, using condescending language, and displaying impatience with inquiries. Although bullying is not unique to the healthcare workplace, historically, a tolerance to behavior characterized as intimidating and very disruptive has been reported.
The behaviors can be exhibited by a range of healthcare personnel, such as nurse colleagues, physicians, pharmacists, or supervisors. The Institute for Safe Medication Practices (ISMP) conducted a study in 2004 on workplace intimidation (n=2,095): 48% of respondents reported being subjected to strong verbal abuse; 43% experienced threatening body language; and 4% reported physical abuse.
According to the study, physicians and other prescribers engaged in intimidating behaviors twice as frequently as nurses, pharmacists, and supervisors. These behaviors included condescending language, a reluctance to answer questions, and impatience with answering questions or returning phone calls.
A surprising finding was that a nurse with less than 2 years experience was subjected to these behaviors less frequently than more seasoned nurses. The noted exception was that a newer nurse asked another professional to intervene with an intimidating person regarding a drug safety issue more often than a more experienced nurse would do, perhaps indicating a lack of confidence.
The International Council of Nurses (ICN) fact sheet on workplace bullying in the health sector (www.icn.ch/matters_bullying.htm) recognizes workplace bullying as one of the fastest growing areas of workplace violence and gives statistics from various countries. The fact sheet lists effects of this problem, including low staff morale, job dissatisfaction, increased absenteeism and attrition of staff, in addition to deterioration in the quality of patient care. Risk factors for workplace bullying include stress, tensions, and frustrations; poor management skills and policies; lack of training to recognize or cope with bullying; and lack of reporting systems or punishment of perpetrators. ICN offers suggested actions and position statements as well.
Healthcare personnel perceive a lack of accountability for disruptive behavior. This was reflected in the ISMP survey as well as in a finding in a VHA, Inc. survey (n=2,562) that included 389 physicians, 104 senior level executives, and 1,615 nurses. Two thirds of all respondents reported having a code of conduct in place at their healthcare organization; of this group, 50% responded that the codes of conduct were effective. Thirty-seven percent of respondents reported that nurses are leaving their hospitals as a result of disruptive behavior. This survey specifically looked at the physician-nurse relationship.
The VHA, Inc. survey also found a difference in the perceptions of the physicians, nurses, and executives surrounding causes, responsibilities, barriers, and solutions to the physician-nurse relationship issues. Some of the contributing factors identified as problematic can be changed. Factors include cultural intolerance, leadership support and the development of appropriate policies, roles, and responsibilities for setting behavioral expectations.
The ANA’s Code of Ethics relates the importance of respect in relationships with colleagues and others. The care of the patient requires a team approach. The team must have healthy relationships to provide optimal care to the patient. What occurs when disruptive behavior is exhibited is a direct threat to patient safety.
Effective January 1, 2009, The Joint Commission is initiating a new leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two of its elements of performance (EP): in EP 4—Hospitals/organizations will have a code of conduct defining acceptable and disruptive and inappropriate behaviors; and in EP 5—Leaders will create and implement a process for managing disruptive and inappropriate behaviors. The Joint Commission has identified other suggested actions, which can be found in its July 9, 2008 Sentinel Event Alert (www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm).
The time has come to create a new history in healthcare workplaces by recognizing that inappropriate behaviors exist but will no longer be tolerated. Healthcare personnel must provide an environment of respect and commit to freeing the workplace of the intolerable burden of disruptive behavior, thereby enhancing the healthcare team’s performance while delivering high quality patient care.

Nancy L. Hughes is Director of ANA’s Center for Occupational and Environmental Health.